A long-term follow-up study on risk factors for hepatocellular carcinoma among Japanese patients with liver cirrhosis

To identify virological parameters (serostatus of hepatitis B surface antigen [HBsAg] and antibodies to hepatitis C virus [anti-HCV], HCV genotypes and HCV-RNA titer) and other clinico-biological and lifestyle variables that may influence or predict the development of hepatocellular carcinoma (HCC) in cirrhosis, we followed 100 cirrhotic patients without HCC, who visited Kyushu University Hospital between 1985 and 1987, until the end of 1995 (follow-up rate: 98%; average follow-up period: 5.3 years). After elimination of 4 patients who developed HCC or were censored within the initial 6 months, 37 (39%) out of 96 patients developed HCC during follow-up. As compared with HBsAg(+) patients, anti-HCV(+) HBsAg(-) patients demonstrated significantly elevated HCC risk (adjusted hazard ratio [HR] = 5.85, 95% confidence interval [CI] 1.65-20.67). Genotype 1 HCV infection was not associated with increased risk compared with genotype 2 (HR = 0.64, 95% CI 0.21-1.99). For genotype 1 HCV infection, patients with HCV-RNA levels < 1 Meq/ml tended to present lower risk than patients with > or = 1 Meq/ml (P = 0.03). Male sex, advanced Child's class, lower serum albumin, and higher serum aminotransferase and alpha-fetoprotein were also found to be strong predictors. Overall, drinking and smoking habits were not associated with significantly elevated risk. Among virological parameters, anti-HCV positivity and, possibly high HCV-RNA titer, were predictive of HCC occurrence in cirrhosis in our clinical setting.

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

BACKGROUND

The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices.

STUDY DESIGN

Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints.

RESULTS

The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months).

CONCLUSIONS

The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.

Laparoscopic splenectomy for an inflammatory pseudotumor of the spleen: operative technique and case report

The case of a primary inflammatory pseudotumor of the spleen in a 44 year-old female is herein reported. This lesion is extremely rare, with only 33 cases previously reported. The splenic tumor was preoperatively diagnosed as a hemangioma by the combined modalities of ultrasonography, computed tomography and magnetic resonance imaging. A laparoscopic splenectomy was, thus, performed in order to make a final diagnosis. Pathological examination of the mass revealed an inflammatory process. Based on the above findings, a laparoscopic splenectomy is recommended when the tumor is suspected to be benign.

Early experience of endoscopic extirpation of benign breast tumors via an extra-mammary incision

The early results of 6 patients with a benign breast mass who underwent an endoscopic extirpation via an extra-mammary incision were presented. Under general anesthesia in either a lateral or supine position, a 12-mm and two 5-mm incisions in the infra-mammary line in 2 patients and in the mid-axillary line in the remaining 4 patients were made. The tumors were then endoscopically extirpated. Preoperative aspiration needle cytology revealed six fibroadenomas in 5 patients and one intraductal papilloma in the other patient. All patients were single females with a mean age of 22.5 years. The maximal size of the masses was 5 cm on average. The average operation time was 3 hours 20 minutes. Regarding postoperative complications, subcutaneous emphysema extending to the neck due to CO2 gas inflation and a burn in the skin were seen in 1 patient each; however, no further treatment was required in these cases. The postoperative hospital stay was 1.7 days on average, and all patients were extremely satisfied with the cosmetic results of the procedure. The cosmetic results are drastically improved by the application of endoscopic removal via extra-mammary approaches, which are newly introduced, for benign breast tumors.

Transaxillary approach for the endoscopic extirpation of benign breast tumors

Cosmetic factors in the treatment of breast disease have long been neglected despite the fact that patients are highly concerned about the length and extent of the incision. Recent developments in both endoscopy and endoscopic devices have now made it possible to reach breast mass(es) from small incisions in the axilla. We describe the successful extirpation of a giant fibroadenoma of the breast in a 20-year-old woman, using a 3-mm or 10-mm endoscope and a 3-mm or 5-mm endoscopic device with a transaxillary approach. A scar-free breast with an excellent cosmetic result was achieved by use of this technique and these devices. Benign tumors (both single large tumors and multiple masses) are therefore considered to be ideal candidates for this type of minimally invasive endoscopic surgery.

Laparoscopic repair of a perforated duodenal ulcer in two patients

The laparoscopic repair of a perforated duodenal ulcer was effectively done in two patients both of whom were poor risks for surgery. One was a 39-year-old woman with a history of bronchial asthma since she was 20 years of age, while the other was a 76-year-old man with hepatocellular carcinoma, lung cancer, and diabetes mellitus. The postoperative course of these patients was uneventful. Based on these findings, the laparoscopic repair of a perforated duodenal ulcer should thus be considered as a first choice of treatment for a perforated duodenal ulcer, even in poor-risk patients.

Long-term results of corticosteroid administration via appendicostomy in patients with ulcerative colitis involving the entire colon

BACKGROUND

Ulcerative colitis (UC) of an unknown etiology frequently demonstrates repeated active and inactive stages. As a result, it is difficult to sustain long-term remission under conservative therapy.

METHODS

Ten patients who presented suffering from UC involving the entire colon were treated. All patients had been previously treated at other hospitals usually with sulphasalazine and either corticosteroids or steroid enemas for the primary complaints of muco-bloody stool or frequent diarrhea. All patients underwent either an appendicostomy or cecostomy, and were injected with dexamethasone via an artificial fistula twice a day.

RESULTS

This treatment led to remission, and, as a result, the symptoms of anal bleeding or muco-bloody stools disappeared in all patients. Radiological, endoscopic, and pathological studies revealed a dramatic response to steroid injection from the fistula. The mean follow-up period was 44.7 months (3-122 months). Eight patients remained free from any symptoms of UC. One underwent a proctocolectomy because of side effects due to steroid treatment. The other patient died suddenly of unknown causes. The mean symptom-free period after cecal injection was 39.5 months (1-119 months). The mean proportion of disease free period from UC, compared with the total follow-up period after surgery, was 88%. After remission, eight patients were able to return to a normal lifestyle at home using a peritoneal button. They could also take a bath and continue their school or social lives in almost the same way as healthy persons.

CONCLUSIONS

We thus recommend this new, minimally-invasive therapy for patients with UC involving the entire colon who demonstrate resistance to conventional conservative therapy. As a result of such treatment, all patients were able to achieve a comfortable lifestyle after undergoing minimally-invasive surgery.

The clinical management and results of surgery for acute cholecystitis

The laparoscopic approach to acute cholecystitis is not only feasible, but it is also a cost-effective, safe, and beneficial treatment option in selected patients. Patients undergoing laparoscopic surgery for acute cholecystitis seem to enjoy the same benefits of diminished pain and shorter hospitalization as those patients undergoing an elective laparoscopic cholecystectomy. The complication rates are also comparable with those for an open cholecystectomy. An early laparoscopic cholecystectomy within 4 days of the onset of symptoms has been shown to reduce the number of major complications and conversion rate, thus resulting in a decreased hospital stay. A low threshold for conversion to laparotomy also seems to be an important factor in maintaining a low incidence of operative complications. The conversion to laparotomy is therefore considered to be a good surgical option for experienced surgeons. Patients who are in the high-risk category or who have severe disease are best managed initially by gallbladder drainage unless they have perforated disease, which thus requires an emergency laparotomy.

Giant gastric varices after a left gastric venous caval shunt operation for esophageal varices: a case report

A Japanese woman, who had undergone a left gastric venous caval shunt operation for esophageal varices 17 years earlier, was admitted to our hospital because of bleeding from giant gastric varices. An angiographic examination revealed a stealing of the portal blood flow to the inferior vena cava through both a dilated right gastroepiploic vein and a right gastric vein via the left gastric venous caval shunt. The gastric varices disappeared after obliterating both the feeding and drainage vessels by means of intervention radiology. We thus, consider the occlusion of both the afferent and efferent vessels to be an effective treatment for gastric varices.

The development of extrahepatic portal obstruction after undergoing multiple operations for a congenital dilatation of the bile duct: report of a case

As a long-term complication after undergoing a cystenterostomy for a congenital dilatation of the bile duct, liver cirrhosis due to stenosis of the anastomosis or reflux cholangitis has been reported in conjunction with subsequent portal hypertension. We treated a 48-year-old Japanese woman who developed both portal hypertension and pancytopenia after undergoing multiple operations for a congenital dilatation of the bile duct. She underwent a Hassab's operation in July 1994, when an occlusion of the extrahepatic portal vein, which resulted in portal hypertension, was first noted; the liver was microscopically normal. The etiology of the extrahepatic portal obstruction in our patient was most likely due to either repeated inflammation or adhesion at the hepatic hilus. Based on these findings, the differential diagnosis of portal hypertension after an operation for a congenital dilatation of the bile duct should therefore include an extrahepatic portal obstruction in addition to liver cirrhosis.

Morphology and proliferation of B16 melanoma cells in the presence of lanthanoid and Al3+ ions

The effects of trivalent metal ions such as lanthanoid (La3+, Ce3+, Nd3+, Sm3+, Gd3+, Er3+, Yb3+, Lu3+) and Al3+ ions on the morphological change and proliferation of B16 melanoma cells in culture are discussed. These metal ions induced morphological transformations and decreased growth rates at doses of 1 mM. B16 melanoma cells treated with La3+, Ce3+, Nd3+, Sm3+, and Gd3+ showed polyhedrical spreading. Elongation of axones was dependent on the metal ions. B16 melanoma cells treated with Er3+, Yb3+, Lu3+, and Al3+ showed a long slender shape. Growth rates of melanoma cells in the presence of 1 mM of metal ions (La3+, Ce3+, Nd3+, Sm3+, Gd3+, Yb3+, Al3+) were significantly lower than that of control cells. Measurements of cell cycle indicated that the metal ions arrested the transitions from G0/G1 to S state.

Laparoscopic splenectomy with the newly devised morcellator

BACKGROUND/AIMS

One of the major hurdles to overcome in the development of laparoscopic surgery has been finding effective extraction techniques for the removal of large tissue masses. The electromechanical morcellator makes it easy to remove relatively large sections of tissue from the abdomen through the existing incisions. To determine the safety and efficacy of the new morcellator in laparoscopic splenectomy, our preliminary experiences using the morcellator were reviewed and retrospectively compared with the results in patients who previously underwent conventional extraction techniques.

METHODOLOGY

From February 1992 to March 1996, 31 patients underwent laparoscopic splenectomy. In the last eight patients, the new morcellator was used to remove the spleen, while in the remaining 23 patients, a laparoscopic splenectomy was performed using the conventional extraction techniques.

RESULTS

In the last eight patients who underwent laparoscopic splenectomy, the newly devised morcellator was successfully used without any complications. The spleen could be removed from the abdominal cavity in an average of 15.9 +/- 10.4 minutes using the morcellator, while the average was 45.7 +/- 15.4 minutes using conventional techniques. It was not necessary to extend the skin incision in patients with the morcellator, while, on the other hand, a 2-cm extension of the existing skin incision was always required to remove the spleen in the latter method.

CONCLUSION

The morcellator was found to be an effective device which can safely, efficiently and rapidly remove tissue masses. This procedure is therefore considered to be one feasible way to solve the age-old problem of intracorporeal morcellation.

Jejunal variceal bleeding after esophageal transection in a patient with idiopathic portal hypertension

This report describes a 38-year-old man with massive gastrointestinal bleeding from jejunal varices. He had been previously diagnosed to have idiopathic portal hypertension and esophageal varices, and had undergone an esophageal transection 8 years earlier. The pre-operative diagnosis was a suspected hemorrhage from the small intestine as visualized by 99mTc-HSAD scintigraphy (technetium 99m-labeled human serum albumin D-type) and was not considered to be repeated massive lower GI tract bleeding. An exploratory laparotomy was performed, and intra-operative endoscopy revealed active bleeding from the jejunal varices. A partial resection of the small intestine resulted in a complete resolution of the bleeding. A review of the literature thereafter disclosed twelve previously reported cases of jejunal variceal bleeding.

Soluble thrombomodulin and antibodies to bovine glomerular endothelial cells in patients with Henoch-Schönlein purpura

AIM

To evaluate the clinical significance of soluble thrombomodulin and antiendothelial cell antibodies (AECA) in children with Henoch-Schönlein purpura.

METHODS

Binding of serum AECA to bovine glomerular endothelial cells was evaluated by enzyme linked immunosorbent assay, cytotoxicity against glomerular endothelial cells by spectrophotometric assay, and soluble thrombomodulin concentrations by sandwich enzyme immunoassay.

RESULTS

IgA AECA were detected in seven of 15 patients with Henoch-Schönlein purpura and nephritis, but were not detected in patients without nephritis or in controls. Patients with Henoch-Schönlein nephritis had raised titres of IgA AECA and serum thrombomodulin; severe proteinuria and renal histological changes were associated with raised titres of IgA AECA and raised serum thrombomodulin. No subjects had complement dependent cytotoxicity against glomerular endothelial cells.

CONCLUSIONS

High titres of IgA AECA and raised serum thrombomodulin may be clinically useful markers of renal involvement in patients with Henoch-Schönlein purpura.

Laparoscopic repair of a paraesophageal hiatal hernia with gastric volvulus

We report the case of a massive paraesophageal hiatal hernia with gastric volvulus which presented with the symptom of a precordial sense of pressure for over two years, which was successfully treated with laparoscopic surgery. The patient is presently in good condition, without any recurrence of either the hiatal hernia or other symptoms one year after surgery. This approach is considered to be a safe and effective procedure, and it also provides for rapid recovery from the operation.

Needle and trocar injury during laparoscopic surgery in Japan

BACKGROUND

With the growth and sophistication of laparoscopic surgery, increased attention is now being focused on safety and complications.

METHODS

In an attempt to address questions regarding the safety of laparoscopic surgery, a retrospective study of the time period from January 1991 to December 1995 was conducted by the Study Group of Endoscopic Surgery in Kyushu, Japan.

RESULTS

The response rate was 84.4% (152 of 180 hospitals). During the last 5 years 17,626 patients underwent endoscopic operations and 87.5% (15, 422 patients) had laparoscopic surgery while 12.5% (2,204 patients) underwent thoracoscopic surgery. In 96.6% of the hospitals a minimal open laparotomy was used. Among the various operations, a cholecystectomy was performed in the largest number of patients (13, 787). The total number of complications was 415 (2.7%), of which 156 (37.6%) were related to needle or trocar insertion. Visceral injury was found in 22 patients (0.14%): major vessel injury in 10, gastrointestinal tract injury in 11, and liver injury in one patient. Abdominal wall injury was seen in 79 patients (0.52%), bleeding in 70 (0.46%), and a hernia in 9 (0.06%). Extraperitoneal insufflation occurred in 55 patients (0.36%). There was no mortality. The complication rate significantly decreased year by year after the use of laparoscopic surgery began.

CONCLUSIONS

The most common complications of laparoscopic surgery are related to needle and trocar insertion. These are preventable by placement under direct vision with verification of the intraperitoneal location of the needle and trocar.

Endotoxin contamination in fetal bovine serum and its influence on tumor necrosis factor production by macrophage-like cells J774.1 cultured in the presence of the serum

Trace amounts of endotoxin (lipopolysaccharide: LPS) are assumed to contaminate commercially available fetal bovine serum (FBS) for tissue or cell culture during the manufacturing process. We examined how cultured cells were affected by the endotoxin and how much endotoxin was in the FBS. Macrophage-like J774.1 cells maintained in RPMI1640 medium supplemented with FBS containing low doses of LPS for 15 or 21 days showed less TNF production in response to LPS than the cells maintained under LPS-free conditions, and the affected responses of the cells were not recovered by an additional 21 day culture in medium with LPS-free FBS. Concentrations of LPS in 40 lots of FBS obtained from 13 international manufacturers were measured by a highly sensitive and LPS-specific chromogenic limulus assay. The median of endotoxin levels in these lots was 46 ng/ml and the maximum was 38.8 ng/ml. Relatively higher concentrations of LPS (> 1 ng/ml) or lower levels (< 10 pg/ml) were found in 9 and 6 lots, respectively. The majority of the FBS lots contained various levels of (1-->3)-beta-D-glucan, and all lots contained high-density lipoprotein (HDL). However, no correlation was found between LPS and (1-->3)-beta-D-glucan or HDL level in the lots. Each FBS was added to macrophage-like J774.1 cells which had been maintained in LPS-free medium. Five lots of FBS induced significant TNF production by the cells without addition of any stimulant. These active 5 FBS contained relatively higher levels of LPS and pretreatment of the FBS with polymyxin B eliminated their ability to induce TNF production. No correlation was found between (1-->3)-beta-D-glucan levels in FBS and the TNF-inducing capability of FBS. These results show that considerable lots of FBS contain significant levels of LPS, which must affect cell culture.

Cerebrovascular selectivity and vasospasmolytic action of the novel calcium antagonist (+/-)-(E)-1-(3-fluoro-6, 11-dihydrodibenz[b,e]oxepin-11-yl)-4-(3-phenyl-2-propenyl)-piperazine dimaleate in isolated cerebral arteries of the rabbit and dog

The cerebrovascular selectivity and vasospasmolytic action of AJ-3941 ((+/-)-(E)-1-(3-fluoro-6, 11-dihydrodibenz[b,e]oxepin-11-yl)-4-(3-phenyl-2-propenyl)-p iperazine dimaleate. CAS 143110-70-7), a new calcium antagonist, were studied in isolated rabbit and dog arterial preparations. In rabbit arterial ring preparations, AJ-3941 dose-dependently inhibited the contractions of various arteries caused by high K(+)-depolarization (high K+) and prostaglandin F2 alpha (PG). The inhibitory potency of AJ-3941 varied in different arteries, in descending order as follows: high K+: basilar > coronary > femoral > renal > mesenteric artery, PG: basilar > coronary > > femoral and renal artery. The median inhibitory concentration (IC50) in the basilar artery was over 40 times lower than that in the mesenteric or femoral artery for which the weakest inhibition in the examined arteries was observed. This selective action of AJ-3941 for cerebral artery was also observed in the frontal and middle cerebral arteries of dogs. The selectivity for the rabbit basilar artery was higher than those of flunarizine and nicardipine. Additionally, the contractile response of the rabbit basilar artery induced by phorbol 12,13-dibutyrate (PDBu), an activator of protein kinase C (PKC), was greater than those of the arteries examined such as the coronary, femoral and mesenteric arteries. The response in the basilar artery was greatly reduced in Ca(2+)-free medium, while this was not the case in other arteries. AJ-3941 as well as H-7, an inhibitor of PKC, potently inhibited PDBu-induced contractile response in the basilar artery in the presence, but not in the absence of Ca2+ in the medium, whereas the existing calcium antagonists, diltiazem and nicardipine, did not inhibit the contractile response in both conditions. These results suggest that the PKC-dependent system which is mediated by influx of extracellular Ca2+ profoundly contributes to the contraction of the cerebral artery and that the cerebroselective-vasodilating effect of AJ-3941 may depend, at least partly, on the inhibition of the PKC-mediated contractile response. In rabbit basilar arteries, AJ-3941 caused a dose-dependent inhibition of the contraction induced by various vasospasmogens, such as endothelin-1 (ET), arachidonic acid, 15-hydroperoxy-eicosatetraenoic acid and the thromboxane A2-mimetic U-46619. Furthermore, when isolated basilar arteries of the dog were perfused intraluminally with AJ-3941 at the concentration that inhibits high K(+)- or PG-induced contraction in the rabbit basilar artery, AJ-3941 effectively antagonized the vasospasm induced by extraluminal application of PG or ET. However, when flunarizine, nicardipine, diltiazem or verapamil was used for intraluminal perfusion of the same preparations, none of these drugs exerted spasmolytic effect. These results indicate that AJ-3941 has cerebrovascular selective-vasospasmolytic action, and consequently is thought to be effective in cerebrovascular disorder such as vasospasm following subarachnoid hemorrhage.

Eradication of large gastric varices by sclerotherapy combined with percutaneous transhepatic obliteration

BACKGROUND/AIMS

The long-term results of a combination therapy of sclerotherapy with percutaneous transhepatic obliteration (PTO) was reviewed in 37 patients with large gastric varices. The study suggests that sclerotherapy combined with PTO can safely and effectively eradicate large gastric varices as an alternative approach to surgery. Complete eradication has also been shown to prevent the recurrence of gastric varices.

MATERIAL AND METHODS

The long-term results of a combination therapy of sclerotherapy with PTO was reviewed in 37 patients with large gastric varices.

RESULTS

Complete eradication of the gastric varices was obtained in 26 patients (70.3%). There was no recurrence of the varices in whom complete eradication had been obtained, but in 11 patients with incomplete eradication gastric varices recurred during the mean follow-up period of 37.5 months. Bleeding occurred in 4 after the treatment and one patient died of massive bleeding from the recurrent gastric varices. There were no major complications with the procedure except for one who had a peripheral pulmonary arterial embolization as a result of a steel coil used for the PTO.

CONCLUSION

This study suggests that sclerotherapy combined with PTO can effectively and safely eradicate large gastric varices and is an alternative approach to surgery for treating patients with gastric varices. It is also shown that complete eradication leads to a prevention of recurrence of gastric varices.

Clinical and angiographic assessments and treatment of patients with recurrent varices after transabdominal transection of the esophagus

BACKGROUND/AIMS

Risk factors regarding the recurrence of esophageal varices and were researched preoperative clinical and angiographic findings in patients with variceal recurrence and/or rebleeding after transabdominal esophageal transection were analyzed.

MATERIALS AND METHODS

Clinical and angiographic assessments of recurrence of varices after transabdominal esophageal transection were made on 55 patients with portal hypertension. In all these patients, postoperative endoscopy was performed at 3-6 monthly intervals.

RESULTS

Varices recurred in 13 patients and 4 patients re-bled during the 5-106 month follow up. There was a significant increase in the rate of recurrence in patients with a history of hematemesis, and in those with a higher grade of development of cephalad collateral vessels in the lesser splanchnic area, as seen on the preoperative portography. Eight of the 13 patients were then effectively treated by endoscopic injection sclerotherapy.

CONCLUSIONS

Despite transabdominal transection of the esophagus, varices may well recur if the patient has had a history of hematemesis and a higher grade of development of cephalad collateral vessels. In such cases endoscopic injection sclerotherapy should be done.

A safe technique for laparoscopic cholecystectomy for incarcerated gallbladder stone

BACKGROUND/AIMS

We present our new laparoscopic technique for treating incarcerated stones in either the cystic duct or the neck of the gallbladder.

PATIENTS AND METHODS

One hundred sixteen patients who underwent laparoscopic cholecystectomy were studied.

RESULTS

In all, 18 patients (16%) were found to have incarcerated stones in gallbladder or cystic duct. Eleven patients were drip infusion cholangiography (DIC) negative. The length of the operative time for these patients was significantly longer than that in non-incarcerated stone cases. We present our new laparoscopic technique for treating incarcerated stones in either the cystic duct or neck of the gallbladder and this procedure includes a needle aspiration of the bile juice, the transsection and removal of the incarcerated stone and an extracorporeal ligation.

CONCLUSIONS

This above procedure was successfully performed on a series of 4 patients. Our procedure is therefore considered to allow us to complete a laparoscopic cholecystectomy even in extremely hypertrophic cases with incarcerated stones either in the cystic duct or Hartmann's pouch.

Serum and synovial fluid levels of interleukin-5 in a patient with eosinophilic fasciitis

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Laparoscopic repair of paraumbilical ventral hernia with increasing size in an obese patient

We report a case of paraumbilical ventral hernia with increasing size over 1 year which was successfully repaired using laparoscopic techniques. The repair was made using a 1-mm-thick expanded polytetrafluoroethylene patch inserted intraperitoneally and then stapled to the anterior abdominal wall over the defect. This laparoscopic repair is easily accessible, is considered to reduce morbidity and is thus recommended as the first choice of treatment for ventral hernia.

Complications of percutaneous transhepatic catheterization of the portal venous system in patients with portal hypertension

We report here complications of percutaneous transhepatic catheterization of the portal venous system in 170 Japanese patients with portal hypertension. All patients underwent percutaneous transhepatic portography and percutaneous transhepatic obliteration of oesophagogastric varices was also performed in 29 patients. After retraction of the catheter, the puncture canal was plugged with gelatin sponge in 150 subjects and with one steel coil in 20 others. The overall complication rate was 16.5%. Intraperitoneal bleeding occurred in 10.6% of patients and 2.9% required blood transfusion. In these patients with intraperitoneal bleeding, the gelatin sponge was used for plugging after retraction of the catheter, while in the 20 patients with a steel coil plug, haemoperitoneum never occurred. Right pleural effusion was recognized in 3.5% of patients, intraperitoneal bile leakage in 1.8% and deterioration of liver function due to arteriovenous fistula in 0.6%. By univariate and multivariate analyses, female gender was the only risk factor for intraperitoneal bleeding among 150 patients investigated by percutaneous transhepatic catheterization of the portal venous system with gelatin sponge plugging. Intraperitoneal bleeding is the most important complication in patients with portal hypertension; it is difficult to predict intraperitoneal bleeding before retraction of the catheter in patients for whom gelatin sponge is used. Thus, for patients undergoing percutaneous transhepatic catheterization of the portal venous system, close follow up is recommended.

Orthostatic hypotension caused by a localised dorsal medullary tumour

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The treatment of gastric varices by a balloon-occluded retrograde transvenous obliteration; a transjugular venous approach

Two Japanese women with a solitary gastric varix were successfully and easily treated by obliterating the gastro-renal shunt with a balloon catheter in a transjugular venous approach without any major complications. The transjugular obliteration was thus found to be a bloodless and useful method for the treatment of a solitary gastric varix with a gastro-renal shunt.

Laparoscopic splenectomy for idiopathic thrombocytopenic purpura: comparison of laparoscopic surgery and conventional open surgery

In chronic idiopathic thrombocytopenic purpura (ITP), the two main therapeutic choices are steroid treatment or splenectomy. The adult form of ITP is described as a disease found primarily in young adults, with a female predominance. Treatment with steroids effects a complete response in less than 30% of patients, whereas splenectomy is successful in more than 60% of patients who undergo it. The minimal access afforded by laparoscopic splenectomy is considered highly desirable for these patients. The purpose of this study was to compare the clinical benefits of a laparoscopic splenectomy with those of conventional open surgery for patients with ITP. From 1968 to 1993, splenectomy was performed on 51 patients: 10 operations done laparoscopically and 41 performed conventionally. Complications, postoperative pain, recovery, and hospital charges were then compared. Laparoscopic splenectomy involved minimal incisions, and a significantly lower frequency of analgesia was required for postoperative abdominal pain (1.3 vs. 3.3); hospital stay was shorter (8.2 vs. 20.1 days) (p < 0.005). Operative time was significantly longer for the laparoscopic surgery (249.2 vs. 99.8 min) (p < 0.0001), but blood loss was less (176.0 vs. 511.7 g) (p < 0.01). No intraoperative or postoperative major complications occurred with the laparoscopic procedures, compared with 46.3% with conventional surgery. Finally, the total hospital costs were lower with laparoscopic splenectomy, especially for postoperative care (p < 0.05). A laparoscopic splenectomy may well be considered the surgical treatment of choice for patients requiring a splenectomy in view of both quality of life and economy.

Periventricular leukomalacia associated with hypocarbia

We here report a case of periventricular leukomalacia (PVL) associated with hypocarbia which remained even after extubation. The patient had no risk factors affecting PVL development other than hypocarbia. We consider that the irregular tachypnea, which remained after extubation might be attributable to overdriving of ventilation of central neurogenic origin. Our patient's clinical course suggests that sodium bicarbonate drip infusion is a very effective way to alter the set point of respiratory neuronal drive of the patient with central neurogenic hyperventilation.

Extreme hyperbilirubinemia induced by endoscopic injection sclerotherapy in a patient with esophageal varices and thalassemia: report of a case

We describe herein the case of a 57-year-old man with thalassemia who developed acute liver failure after undergoing endoscopic injection sclerotherapy (EIS) to control hemorrhage from a ruptured esophageal varix. The patient, who had been confirmed as having liver cirrhosis due to chronic hepatitis C with thalassemia in 1989, was admitted to our department to undergo EIS for esophageal varices, at which time his serum total bilirubin level was 5.5 mg/dl. As a small amount of hematemesis occurred just after a percutaneous transhepatic portography was performed, emergency EIS was carried out, following which the serum total bilirubin level markedly increased, mainly with a direct fraction, until it reached 70 mg/dl. The patient eventually died from acute liver failure with extreme hyperbilirubinemia on the 27th day after experiencing hematemesis despite all treatment. This unfortunate case demonstrates that sclerotherapy could be an inappropriate method of treatment for patients with hemolytic disease.

Effect of teprenone on portal hypertensive gastric mucosa

Teprenone (geranylgeranylacetone) is a gastric mucosal protective drug used clinically in Japan for treatment of gastric ulcers and gastritis. Its effect on portal hypertensive (PHT) gastric mucosa which has impaired defensive mechanisms is not known. In 20 PHT and 20 sham-operated rats, we studied the effects of teprenone or placebo on: (1) portal pressure; (2) gastric pH; (3) gastric mucosal blood flow using laser doppler flowmetry, and (4) hexosamine content in gastric mucosa. The gastric mucosal blood flow was significantly higher in the PHT + teprenone group than in the PHT + placebo group (463 +/- 75 and 381 +/- 82 perfusion units, respectively; p < 0.05). The hexosamine content was significantly lower in PHT rats than in sham-operated controls (12.6 +/- 2.3 vs. 14.3 +/- 2.2 micrograms/mg, respectively). Teprenone treatment significantly increased the gastric mucosal hexosamine concentration in both sham-operated and PHT rats (17.2 +/- 3.1 and 15.6 +/- 3.6 micrograms/mg, respectively). These effects of teprenone, combined with its known prostaglandin-stimulating action, suggest a potential role for this agent in the treatment of PHT gastric mucosal abnormalities.

The role of the spleen, platelets, and plasma hepatocyte growth factor activity on hepatic regeneration in rats

BACKGROUND

Hepatocyte growth factor (HGF) is a humoral factor that may act as a trigger for hepatic regeneration. In this study, changes in the plasma HGF activity on hepatic regeneration in a splenectomized condition were measured for the first time, while the role of the spleen and platelets on hepatic regeneration were also carefully evaluated.

STUDY DESIGN

Seventy-five male Wistar rats were classified into three groups: group A consisted of rats who underwent a sham operation and a partial hepatectomy; group B consisted of those who underwent a splenectomy and partial hepatectomy; and group C consisted of those who underwent a splenectomy, partial hepatectomy, and were administered an antiplatelet agent.

RESULTS

At 24 hours after partial hepatectomy, the weights of the livers of the rats in groups B and C were significantly greater than those of group A, while the labeling index of group C was significantly higher than that of group A and also tended to be higher than that of group B. Regarding the number of platelets, the transient increase in group A occurred earlier than that of either group B or C. The plasma HGF activities also showed a transient increase and the maximum levels were reached at 24 hours in group A, six hours in group B, and 12 hours in group C.

CONCLUSIONS

It is suggested that the spleen plays an inhibitory role in hepatic regeneration. In the early stage of hepatic regeneration, platelets possibly control HGF induction, while in the following stage, a possible feedback mechanism is also postulated to exist.

Noninvasive variceal pressure measurement may be useful for predicting effect of sclerotherapy for esophageal varices

This study assessed the relationship between variceal pressure and morphological findings and hemodynamics of esophageal varices as well as the effect of sclerotherapy. Esophageal variceal pressure was measured in 40 patients with portal hypertension, using a noninvasive method. Esophageal variceal pressures were significantly higher in moderate or large varices than they were in small varices. Variceal pressures were significantly higher in patients with red color signs on the varices than in those without. According to the percutaneous transhepatic portography, the structure of the esophageal varices was classified into two types: the bar type and the palisading type. The maximum variceal pressure was significantly higher in the bar type than in the palisading type. In patients who underwent more than five sessions of sclerotherapy, the variceal pressure was significantly higher than in those receiving less than four sessions. These results suggest that variceal pressure may well reflect the vascular pattern and be useful for predicting the effect of sclerotherapy.

Laparoscopic hepatic resection for hepatocellular carcinoma

Despite recent progress in diagnostics for hepatocellular carcinoma, the rate of resectability remains low, mainly because of the advancement of the underlying liver disease. We report a case of a 54-year-old man with a hepatocellular carcinoma and poor liver function that was treated successfully with a laparoscopic hepatic resection. Laparoscopic hepatic resection is considered to be feasible with the aid of an ultrasonic dissector and a microwave coagulator; however, close attention should be paid to the development of air embolism and hepatic vein injury.

Development of early squamous cell carcinoma of the esophagus after endoscopic injection sclerotherapy for esophageal varices

A 56-year-old Japanese man with liver cirrhosis was admitted to Kyushu University Hospital in September, 1986 for the treatment of large esophageal varices. Endoscopy revealed four tortuous folds of large esophageal varices, extending proximally from the esophagocardial junction to 34 cm from the dental arch. Endoscopic injection sclerotherapy was performed on the lower esophagus using 5% ethanolamine oleate, and esophageal varices were completely eradicated in 5 sessions with a total of 70 ml of sclerosant. In March 1991, 4 years and 6 months after the treatment, endoscopy revealed a mild redness and an irregular surface 33 cm from the dental arch. The histologic diagnosis was squamous cell carcinoma. The possible relationship between sclerotherapy and the development of esophageal carcinoma should be considered.

Hemodynamic analysis of findings in patients with portal hypertension: multicenter analysis in Japan. Japan Portal Hypertension Study Group

BACKGROUND/AIMS

A multicenter study was done to assess the pathophysiology of malcirculation with portal hypertension.

PATIENTS AND METHODS

Patients were admitted to 48 different institutes from 1990 to 1992.

RESULTS

Portal venous pressure was 345.9 +/- 72.1 mmH2O in patients with portal hypertension. In patients with liver cirrhosis, the diameter of the splenic artery, of the proper hepatic artery, of the left gastric artery and of the splenic vein was significantly larger (p<0.05) than seen in the controls without portal hypertension. In patients with idiopathic portal hypertension, the diameter of the splenic artery and of the vein was significantly larger (p<0.05) and that of the proper hepatic artery was significantly smaller (p<0.05) than seen in the cirrhotic patients. In the cirrhotic patients, blood flow volume was significantly larger (p<0.05) in the splenic vein. In patient with idiopathic portal hypertension, blood flow volume in the portal vein and splenic vein were significantly larger (p<0.05) and that of superior mesenteric vein showed an increasing tendency to enlarge.

CONCLUSION

This study shows that a hyperdynamic state is present in patient with portal hypertension.

Prognostic significance of hepatic vein waveform by Doppler ultrasonography in cirrhotic patients with portal hypertension

OBJECTIVE

We prospectively evaluated the prognostic value of the flat hepatic vein waveform, measured by Doppler ultrasound, in cirrhotic patients with portal hypertension.

METHODS

The Doppler pattern of right and left hepatic veins in a series of 120 consecutive cirrhotic patients with portal hypertension but without hepatocellular carcinoma was examined, together with clinical and biochemical parameters.

RESULTS

Flat waveform of the right hepatic vein was recognized in nine patients and that of the left hepatic vein was seen in 13. After a mean follow-up of 13.6 +/- 9.7 months, 17 patients died, all from liver failure. In the univariate analysis, variable significantly associated with the duration of survival were age, etiology of the liver cirrhosis, upper gastrointestinal bleeding after start of the study, Child-Pugh score, ascites, encephalopathy, prothrombin index, bilirubin, albumin, and flat Doppler waveform in the right and left hepatic veins. Multivariate analysis showed that flat Doppler waveform in the right hepatic vein, bilirubin, and prothrombin index were independently related to survival.

CONCLUSIONS

The prognostic accuracy in cases of cirrhosis with portal hypertension is significantly improved with acquisition of information obtained from hepatic vein waveform by Doppler ultrasound.

Recurrent rectal bleeding from portal hypertensive colopathy in a patient with hemorrhoids

In a 62-yr-old woman who complained of recurrent rectal bleeding, hemorrhoids with mucosal prolapse were found. Virus-related cirrhosis also was present. Colonoscopy revealed spontaneous bleeding from two rectal ectasias (portal hypertensive colopathy) located 9 cm from the anus. Endoscopic hemostasis was achieved with a heater probe, and there has been no recurrent hemorrhage. Colonoscopy is important in ruling out hemorrhage from portal hypertensive colopathy when rectal bleeding occurs in the presence of portal hypertension.

Sclerotherapy-resistant esophageal varices with enormously enlarged cephalad collateral vessels predictable using portography

BACKGROUND/AIMS

The most common cause of failure of sclerotherapy is recurrent bleeding before eradication is complete. We investigated factors which would make feasible prediction of cases where esophageal varices would be more difficult to eradicate.

PATIENTS AND METHODS

Seven hundred and seventy patients underwent endoscopic injection sclerotherapy at Kyushu University Hospital from January, 1982 to June, 1989. For 580 of these patients we used the same sclerosant and a transparent overtube. For 19 of 580 patients over two months were needed to eradicate the varices (group 2), while eradication was complete in less than one month in 64 patients (group 1).

RESULTS

There was a tendency toward a lower platelet count and a higher indocyanine green retention rate in group 2, but with no statistically significant difference. The number of sessions required for eradication of the varices was 8.1 +/- 2.5 and the total volume of sclerosant used was 98.2 +/- 62.3 ml in group 2, and 3.0 and 47.0 +/- 10.9 ml, respectively, in group 1 (p < 0.01). There was no significant difference in the number of sessions between the patients with large-sized and moderate-sized varices. Based on the extent of cephalad collateral vessels on the venous phase of celiac or superior mesenteric angiography, the vascular pattern could be classified into three types; Grade III, the most developed type was present in 100% and 57.1% on celiac and superior mesenteric angiography in group 2, while the rates were 11.1% and 5.6% in group 1 (p < 0.05).

CONCLUSIONS

This retrospective study shows that in patients with enormously enlarged cephalad collateral vessels it may be difficult to eradicate the varices, and in such cases, preoperative portography is most useful to predict whether or not esophageal varices can be eradicated.

Development of esophageal cancer after endoscopic injection sclerotherapy for esophageal varices: three case reports

We report here three cases of squamous-cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. All three patients were men and cigarette smokers, with a mean age of 58.3 +/- 5.0 years. Hepatitis B and C virus infection tests were negative, and alcoholic cirrhosis was present in each patient. The interval between sclerotherapy and the development of carcinoma was 9, 10, and 33 months, in the respective cases. The sclerosant used was 5% ethanolamine oleate with a mean total volume of 51.0 +/- 18.9 ml. While we have no evidence of a direct relationship between sclerotherapy and esophageal cancer, in patients with alcoholic cirrhosis who have risk factors for esophageal cancer there may be an acceleration of the potential malignancy, as a result of the chronic inflammation related to sclerotherapy. Such patients should be closely followed, using endoscopy.

Increased prostacyclin content in gastric mucosa of cirrhotic patients with portal hypertensive gastropathy

Plasma levels and gastric mucosal contents of prostaglandin (PG) E2 and prostacyclin were determined in cirrhotic patients with portal hypertensive gastropathy (PHG), in cirrhotic patients without PHG and in healthy controls. PGE2 and 6-keto-PGF1 alpha (a stable metabolite of prostacyclin) levels were measured in 30 cirrhotic patients and 10 controls, using radioimmunoassay. Of 30 cirrhotics, 13 had PHG of the fundus and the corpus. Plasma concentrations of 6-keto-PGF1 alpha in the cirrhotic patients were significantly higher than in the controls (p < 0.01), but there was no significant difference between cirrhotics and controls with regard to plasma levels of PGE2. The gastric mucosal contents of 6-keto-PGF1 alpha in the fundus was significantly higher in cirrhotics with PHG than those without PHG (p < 0.05) and controls (p < 0.01). However, the gastric mucosal contents of PGE2 in the fundus were not significantly different in cirrhotics with and without PHG. The gastric mucosal contents of 6-keto-PGF1 alpha significantly correlated to the plasma levels (r = 0.37, p < 0.05), but there was no significant correlation between plasma levels and gastric mucosal contents of PGE2. Since prostacyclin has vasodilator and gastric acid inhibitory effects, we speculate that high contents of prostacyclin in the gastric mucosa may have some role in the pathogenesis of PHG.

Portal venous blood flow unaltered in cirrhotic patients given metoclopramide injections

The effects of metoclopramide on blood flow in portal and left gastric veins and cardiovascular haemodynamic variables were studied in 30 patients with both liver cirrhosis and oesophageal varices. Measurements were made under baseline conditions and after the intravenous administration of saline, metoclopramide 10 mg, and metoclopramide 20 mg. Portal haemodynamics, including portal and left gastric veins were studied using pulsed Doppler ultrasound. In all groups, the blood flow and the maximal diameter of portal and left gastric veins, and heart rate remained unchanged. However, metoclopramide 10 mg significantly decreased the mean arterial pressure 15 minutes after administration while metoclopramide 20 mg decreased it 30, 45 and 60 minutes after administration. Therefore, metoclopramide apparently does not alter the blood flow of the portal venous system in these patients.

Endoscopic injection sclerotherapy for esophageal varices associated with concomitant portal venous thrombus of hepatocellular carcinoma

Between 1983 and 1994, we treated 51 patients with esophageal varices and portal trunk and main branch invasion of hepatocellular carcinoma, using endoscopic injection sclerotherapy. Variceal bleeding was controlled in 28 of 29 patients (96.6%), esophageal varices were completely eradicated in 28 (54.9%), and only 2 of 28 (7.1%) bled from small, dilated, venous vessels after eradication. The cumulative nonbleeding rate at 3 years was 87.5%. Death caused by hepatocellular carcinoma accounted for 89.4% of the patients, whereas the rate of bleeding from esophageal varices was 4.3%. Variables significantly associated with the duration of survival were Okuda's clinical stage, alpha-fetoprotein, eradication of esophageal varices by sclerotherapy, and treatment of hepatocellular carcinoma, as determined in a univariate analysis. Multivariate analysis showed that eradication of esophageal varices by sclerotherapy, Okuda's clinical stage, and age were independent factors which significantly influenced survival time. We propose that complete eradication of esophageal varices and close follow-up using endoscopy may lead to a reduction in bleeding from esophageal varices, and hence may reduce mortality rates related to this bleeding.

Modulation of extraluminally induced vasoconstrictions by endothelium-derived nitric oxide in the canine basilar artery

The present study was undertaken to investigate the role of endothelium in extraluminally induced vasospasm of the cerebral artery using isolated perfused canine basilar arteries. The extraluminal applications of high K+ and prostaglandin F2 alpha (PGF2 alpha) induced concentration-dependent vasoconstriction. Both constrictive responses were significantly enhanced by denuding endothelium. Additionally, the responses in the endothelium-intact arteries were markedly augmented by intraluminal perfusion with NG-monomethyl-L-arginine (L-NMMA). These results suggest that the inhibition of nitric oxide (NO) synthase in endothelium enhances increase in transmembrane Ca(2+)-influx which is a common constrictive mechanism to the vasoconstrictors. The augmentative action induced by L-NMMA was inhibited by intraluminal perfusion of L-arginine, but not by D-arginine. Furthermore, the augmentation was not observed in the arteries without endothelium. These results suggest that the endothelium may have a great significance on responsiveness to extraluminal vasoactive substances and that endothelium-derived NO may modulate the extraluminally induced vasoconstriction which is responsible for cerebral vasospasm after subarachnoid hemorrhage.

Classification of gastric lesions associated with portal hypertension

There are two gastric mucosal lesions which commonly occur in patients with portal hypertension; one is portal hypertensive gastropathy and the other is gastric varices. These lesions occasionally cause fatal haemorrhage. Several classifications for these lesions have been proposed, but none of them have been evaluated prospectively. We consider it better to classify portal hypertensive gastropathy into three stages including non-specific redness, specific mosaic pattern and red spots. Gastric varices may be classified according to form, location and mucosal lesions. Prospective trials are needed to obtain more practical evidence for the accurate classification of these gastric lesions.

Feasibility of laparoscopic cholecystectomy for patients with a nonvisualized gallbladder on drip infusion cholangiography

We report here the operative findings, the incidence of successful laparoscopic treatment, and the perioperative complications in patients with nonvisualized gallbladder on drip infusion cholangiography (DIC). Eighty-five patients with a nonvisualized gallbladder on DIC were entered into the study. None of the patients had a minimal adhesive gallbladder; 51 to 85 patients (60.0%) had moderate adhesive gallbladders, and 34 (40.0%) had severely adhesive ones. The rate of successful laparoscopic treatment, including laparoscopy-assisted abdominal surgery, was 97.6% (83 of 85 patients). Perioperative complications occurred in only three patients (3.5%), and there were no deaths related to the operation. Thus, when patients with a nonvisualized gallbladder on DIC undergo laparoscopic cholecystectomy, meticulous procedures must be carried out; however, as the rate of successful laparoscopic treatment is high, cholecystectomy under laparoscopy is feasible for experienced surgeons.